Satisfaction Survey

Your Name (Required)

Your Email Address (Required)

Provider or Staff Member's Name (Required)

Date (Required)

Please indicate the type of service you are receiving: (Required)
TherapyEvaluation/ testingOther (administrative interactions)

Please rate your experience (1=Poor, 5=Excellent):

To what extent did your provider help you achieve your goals?

To what extent did your provider help you obtain new skills?

How well did your provider show interest in your needs?

How well did your provider understand your needs?

How well did your provider help you define your needs?

How well were you involved in treatment planning (goals, frequency)?

How well did your provider respond to your requests for services?

To what extent were you treated with dignity and respect?

Please rate the efficiency and accuracy of scheduling and billing:

Would you continue treatment or return to your provider in the future?
YesNo

Do you have any specific concerns or complaints about your treatment?
YesNo

If yes, please explain:

Were there some things you feel were especially good or helpful?
YesNo

If yes, please explain:

Please provide any additional comments:

By checking here, I give permission for my feedback to be shared anonymously. Our staff love hearing how they are helping to make a difference!
YesNo